Chondral Disease of the Knee - part 6 pot

68
Case 20
FIGURE C20.2. Arthroscopic probing of the trochlear lesion demonstrates a laterally based lesion with soft
fibrocartilaginous repair tissue.
FIGURE
C20.3.
Intraoperative clinical photographs
of the autologous chondrocyte implantation proce-
dure.
(A) Inspection of the trochlear lesion. The
uncontained nature of this laterally based lesion is
evident. Following initial suturing of the periosteal
patch, additional fixation is provided by drilling for
suture anchor placement along the lateral un-
contained edge (B) and anchor placement before
impaction (C).
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Case 20 69
FIGURE
C20.4. Postoperative anteroposterior (A)
and lateral (B) radiographs of the left knee demon-
strate the distal realignment procedure with hard-
ware fixation in place. The two suture anchors
utilized to secure the periosteal patch are also
evident on these radiographic views.
approximately 6 weeks until radiographic
healing of the distal realignment was demon-
strated. She utilized continuous passive motion
for 6 weeks initially with partial flexion restric-
tions.

At 8 weeks, she was advanced to weight
bearing and range of motion as tolerated. She
advanced through the traditional rehabilitation
protocol for ACI of the trochlea. She was asked
to refrain from any impact or ballistic activities
for 18 months.
FOLLOW-UP
At her 6-month follow-up visit, she ambulated
without an antalgic gait, and her knee pain
and swelling had decreased substantially. At
12 months, she was walking for long distances
without pain. Stair climbing was virtually
painfree. She has not begun participating in
gym class or sports activities as yet. However,
she believes that once the protocol permits, she
would be symptom free enough to allow higher-
level activities.
DECISION-MAKING FACTORS
1.
Previously failed microfracture technique
and aggressive physical therapy program
emphasizing proper patellofemoral
mechanics.
2.
Young, high-demand patient without viable
cartilage restoration alternatives.
3.
Persistent symptoms of pain and swelling in
the exact location of the defect.
4.

Ability and willingness to be compliant with
postoperative rehabilitation.
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PATHOLOGY
Failed prior fresh osteochondral allograft of the medial femoral condyle
TREATMENT
Revision fresh osteochondral allograft with medial opening-wedge high tibial
osteotomy and iliac crest bone graft
SUBMITTED BY
Brian J. Cole, MD, MBA, Rush Cartilage Restoration Center, Rush Univer-
sity Medical Center, Chicago, Illinois, USA
CHIEF COMPLAINT AND
HISTORY OF PRESENT
ILLNESS
The patient is an 18-year-old male who has had
symptoms of bilateral knee pain for 5 years
before his initial evaluation. His symptom onset
was sudden, occurring while playing football.
Two
years previously, because of ongoing symp-
toms of osteochondritis dissecans of both
medial femoral condyles, he underwent bilat-
eral osteochondral allograft transplantation
using fresh osteochondral allografts. The right
knee was treated with an opening-wedge
osteotomy due to a sHght varus deformity, and
the left knee, because of what was beheved
to be a minimal varus deformity, was left
untreated without an osteotomy. The patient

did well with respect to the right knee and
became completely asymptomatic. However,
his left knee remained symptomatic, with com-
plaints of medial knee pain on a daily basis with
weight-bearing activity-related swelling,
stiff-
ness,
and inability to participate in sports. He
has minimal mechanical symptoms. He would
like to participate in intramural and high school
level sports but is unable to do so.
PHYSICAL EXAMINATION
Height, 5ft, lOin.; weight, 1901b. His gait is
slightly antalgic on the left. The aUgnment
reveals a sUght varus deformity on the left
and normal aUgnment to sUght valgus on the
right. There is a moderate effusion in the left
knee.
His range of motion is 0 to 130 degrees.
He is tender along the medial femoral condyle
and slightly tender along the joint line.
Meniscal findings, however, are grossly
absent. He has 2 cm of quadriceps atrophy in
the left knee when measured 10 cm proximal to
the patella. His ligament examination is
normal.
RADIOGRAPHIC EVALUATION
Posteroanterior flexion weight-bearing radi-
ographs demonstrate collapse of the medial
femoral condyle osteochondral allograft of

the left knee. The osteochondral allograft and
high tibial osteotomy previously performed on
the right knee are both well healed (Figure
C21.1).
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Case 21
71
FIGURE
C21.1.
Flexion weight-bearing
radiograph demonstrates collapse of the
medial femoral condyle osteochondral
allograft of the left knee and well-incor-
porated osteochondral allograft in the
right knee with a well-healed osteotomy.
SURGICAL INTERVENTION
At the time of surgery on his left knee, there
was a necrotic osteoarticular fragment and a
defect measuring 30 mm by
30
mm by
8
mm in
depth (Figure C21.2). The fragment was
removed, and the patient underwent postoper-
ative rehabilitation. Three months later, the
patient underwent left knee osteochondral allo-
graft reconstruction using a

30
mm by 30 mm
fresh osteochondral allograft and a high tibial
opening-wedge osteotomy with an 11-degree
correction and iliac crest bone grafting (Figure
C21.3).
Postoperatively, he was made non-
weight bearing for approximately 8 weeks. He
utilized continuous passive motion and under-
FiGURE C21.2. Arthroscopic view of the defect
cavity within the medial femoral condyle following
removal of the necrotic osteochondral allograft
fragment.
FIGURE
C21.3.
Intraoperative photograph of a
30 mm by 30 mm fresh osteochondral allograft
placed within the medial femoral condyle.
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Case 21
FIGURE 21.4. Eighteen-month radi-
ograph demonstrates heaUng of the
osteotomy and excellent incorporation
of the medial femoral condyle osteo-
chondral allograft with preservation of
the medial joint space.
went progressive strengthening. At 8 weeks, he
was advanced to weight bearing as tolerated. At

6 months, he was permitted to return to activi-
ties as tolerated.
FOLLOW-UP
At his 18-month follow-up visit, he demon-
strated full range of motion, no swelling or
pain, and had returned to all activities. Imaging
studies reveal radiographic incorporation of
his graft without collapse and a well-healed
osteotomy (Figure
C21.4).
At the 3-year follow-
up visit, he was completely asymptomatic.
DECISION-MAKING FACTORS
1.
2.
with symptoms
osteochondritis
sub-
Young, active individual
related to lesion of
dissecans.
Defect size greater than 3cm^ with
chondral bone loss beyond 6 to
8
mm.
3.
Failure of primary treatment with the possi-
bility of biomechanical and biologic failure
of the osteochondral allograft.
4.

Contralateral knee with similar pathology
successfully treated with combined fresh
osteochondral allograft and opening-wedge
high tibial osteotomy.
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PATHOLOGY
Lateral meniscus deficiency
TREATMENT
Lateral meniscus allograft reconstruction
SUBMITTED BY
Brian J. Cole, MD, MBA, Rush Cartilage Restoration Center, Rush Univer-
sity Medical Center, Chicago, Illinois, USA
CHIEF COMPLAINT AND
HISTORY OF PRESENT
ILLNESS
This patient is an 18-year-old accomphshed
collegiate-level basketball player who pre-
sented following a lateral meniscectomy of her
left knee performed 8 months previously,
leaving her with persistent lateral joint line pain
and activity-related swelling. These symptoms
persisted despite having completed a rigorous
postoperative physical therapy program. The
symptoms occurred with routine activities and
prevented her from playing basketball at a
competitive level.
PHYSICAL EXAMINATION
Height,
5

ft,
9
in.;
weight, 1421b. The patient
ambulates with a nonantalgic gait. She stands in
slight symmetric physiologic valgus. She has a
moderate effusion. There is diffuse tenderness
along the lateral joint line with pain created
during placement of a valgus axial load. Her
range of motion was symmetric to the con-
tralateral side. There is approximately 2 cm of
quadriceps atrophy when compared to the
contralateral side. She has no medial joint
line tenderness and a normal Ugamentous
examination. There is no patellofemoral crepi-
tus noted.
RADIOGRAPHIC EVALUATION
Plain radiographs show some flattening of the
lateral femoral condyle of the left knee. There
does not appear to be any bony deficit. There is
no joint space narrowing, but definite irregu-
larity is noted compared to the contralateral
side.
SURGICAL INTERVENTION
Because of her persistent symptoms, she was
indicated for a lateral meniscus allograft trans-
plant. At surgery, it was noted that she had
previously undergone a subtotal lateral menis-
cectomy and had minimal chondral change in
that compartment (Figure C22.1A). Otherwise,

the knee joint was within normal limits. A
lateral meniscal transplant using a keyhole
technique was performed (Figure C22.1B).
Postoperative rehabilitation allowed weight
bearing as tolerated up to 90 degrees of flexion,
which remained restricted for the first 6 weeks.
Return to unrestricted activities was permitted
at 6 months.
FOLLOW-UP
The patient did weU initially and, although she
still had mild lateral joint line pain, it was much
less than what she had experienced preopera-
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Case 22
FIGURE
C22.1.
Arthroscopy of (A) the lateral compartment demonstrating prior subtotal meniscectomy and
(B) the lateral meniscal transplant sutured into position.
tively. At 6 months postoperative, she was able
to run for conditioning, but was not yet able to
participate competitively. At 9 months pos-
toperative, she developed occasional catching
without any significant pain or
swelHng.
She had
full range of motion without evidence of lateral
joint line pain. However, before being fully

cleared for a return to basketball, a diagnostic
arthroscopy was performed to assess for menis-
cal heaUng. At second-look arthroscopy, the
repair was completely intact except for a small
partial tear at the junction of the posterior horn
and body, which was repaired using a formal
inside-out technique (Figure C22.2). Subse-
quent to this procedure, the patient did quite
well, and is
now, 2.5
years after her lateral men-
iscus transplant, participating in all activities
without limitations. Radiographs demonstrate
no change in remaining joint space compared to
her preoperative views (Figure C22.3).
FIGURE
C22.2. Arthroscopy at 9 months postopera-
tively shows an additional suture placed to repair a
small area at the meniscal capsular junction believed
to be contributing to the patient's persistent mechan-
ical symptoms. Note the small area of degeneration
at the posterior horn of the meniscus allograft.
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Case 22 75
B
FIGURE
C22.3.
Two-year postoperative (A) anteroposterior and (B) lateral radiographs demonstrate main-
tenance of the lateral joint space with no evidence of collapse or degenerative changes.

DECISION-MAKING FACTORS
1.
Young, active, high-demand patient with
ipsilateral joint line symptoms following
lateral meniscectomy.
2.
Intact articular cartilage.
3.
Demonstrated ability and understanding to
adhere to rehabihtation protocol.
4.
Unresponsiveness to meniscectomy and
additional nonoperative treatment.
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PATHOLOGY
Prior medial meniscectomy and focal chondral defect medial femoral condyle
TREATMENT
Medial meniscus allograft reconstruction with osteochondral autograft
transplantation
SUBMITTED BY
Brian J. Cole, MD, MBA, Rush Cartilage Restoration Center, Rush Univer-
sity Medical Center, Chicago, Illinois, USA
CHIEF COMPLAINT AND
HISTORY OF PRESENT
ILLNESS
The patient is a 40-year-old woman who had a
previous medial meniscectomy of the left knee,
after which she did well for approximately 5
years.

She presents with moderate to severe
weight-bearing pain and medial joint Une dis-
comfort. She is unable to walk more than two
blocks before having to stop due to increasing
discomfort. She complains of pain at night
when the inner side of her knees rest against
each other. Initial treatment included physical
therapy and a cortisone injection that provided
no relief of her symptoms.
PHYSICAL EXAMINATION
Height,
5
ft,
6
in.;
weight, 1301b. The patient
walks with a slightly antalgic gait. Her left knee
is in neutral alignment compared to the right
knee,
which is in slight physiologic valgus. The
left knee has a small effusion. She has full sym-
metric range of motion. Her medial femoral
condyle and joint line are both tender to
palpation. She has full range of motion, no
patellofemoral crepitus, and a normal ligament
examination.
RADIOGRAPHIC EVALUATION
Preoperative radiographs demonstrate mild
medial joint space narrowing with no signifi-
cant flattening of the medial femoral condyle

(Figure C23.1).
SURGICAL INTERVENTION
At the time of cartilage restoration surgery
(Figure C23.2), she was identified as having a
previous subtotal medial meniscectomy and an
associated grade IV focal chondral defect along
the medial femoral condyle measuring approxi-
mately
10
mm by 10 mm. She underwent allo-
graft medial meniscus transplantation using a
double bone plug technique and osteochondral
autograft transplantation using a single 10-mm-
diameter plug (Figure C23.3). Postoperative
rehabilitation included partial weight bearing
for the first 4 weeks with immediate use of con-
tinuous passive motion for 6h/day for the first 6
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Case 23
77
V^c '^
B
FIGURE
C23.1.
Extension weight-bearing anteroposterior (A) and lateral (B) radiographs demonstrate mild
medial joint space narrowing without flattening of the femoral condyle or significant osteophyte formation.
FIGURE
C23.2. (A) Arthroscopic photograph

obtained at the time of meniscus transplantation
demonstrates prior subtotal medial meniscectomy
with minimal changes in the articular surface of the
tibia. (B) Arthroscopic photograph taken through
the arthrotomy shows the 10 mm by 10 mm grade IV
defect of the medial femoral condyle.
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Case 23
FIGURE
C23.3.
(A) Allograft medial meniscus trans-
plant sutured in place. (B) The 10-mm-diameter
osteochondral autograft is in place, effectively resur-
facing the medial femoral condyle defect.
weeks. Return to unrestricted activities was per-
mitted at 6 months.
FOLLOW-UP
At the 2-year follow-up visit, she demonstrates
no progression of joint space narrowing and
excellent integration of the osteochondral plug
(Figure C23.4). She returned to all activities
with no complaints of pain or swelling.
B
FIGURE C23.4. Two-year postoperative anteroposte-
rior (A) and lateral (B) radiographs demonstrate
preservation of joint space with no progression in
degeneration and full integration of the osteochon-
dral allograft plug with no cystic change or collapse.

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Case 23 79
DECISION-MAKING FACTORS
1.
Active patient in her fifth decade with ipsi-
lateral symptoms beUeved to be related to a
prior subtotal meniscectomy and, possibly, to
the associated defect of her medial femoral
condyle.
2.
Concomitant pathology requiring simulta-
neous treatment to eliminate any con-
traindication to either procedure being
performed in isolation.
3.
Absence of contraindications to meniscus
transplantation including the lack of signifi-
cant malalignment, the absence of bipolar
disease, and a correctable grade IV lesion of
the medial femoral condyle.
4.
Relatively small defect (less than or equal
to approximately Icm^) with a single stage
solution that will restore the surface with
hyahne cartilage.
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PATHOLOGY
Failed anterior cruciate ligament reconstruction with medial meniscus

deficiency
TREATMENT
Revision anterior cruciate ligament reconstruction and medial meniscus allo-
graft reconstruction
SUBMITTED BY
Brian J. Cole, MD, MBA, Rush Cartilage Restoration Center, Rush Univer-
sity Medical Center, Chicago, Illinois, USA
CHIEF COMPLAINT AND
HISTORY OF PRESENT ILLNESS
This 16-year-old male patient is a high school
soccer player who sustained a complete tear
of his anterior cruciate ligament (ACL) during
a soccer game approximately 18 months before
presentation. He underwent ACL reconstruc-
tion using a bone-patella tendonbone autograft.
His postoperative course was uncomplicated; he
had complete rehef of his pain and instability,
and was able to return to playing competitive
soccer. Approximately 11 months later, while
playing soccer he felt a pop in his knee. He came
to arthroscopic evaluation, at which time he was
noted to have a large irreparable bucket-handle
tear of his medial meniscus that required a
subtotal meniscectomy. Although still intact, the
ACL graft was probed and believed to be lax.
At the time of presentation for cartilage restora-
tion, he complained of persistent medial-sided
knee pain, repeated giving-way, and activity-
related effusions.
PHYSICAL EXAMINATION

Height,
5
ft, 10in.; weight, 1451b. The patient
walks with a nonantalgic gait. He stands in
neutral alignment. His range of motion is
symmetric to the contralateral knee without
any prone heel height difference. He has a
trace effusion. He has significant tenderness
along the medial joint line. The Lachman
examination is grade II with firm endpoints, and
he has a grade I to II pivot shift. His KT-
2000 test reveals an 8-mm side-to-side
difference on maximum manual testing. He
has no posterior drop-back or sag, and he has
no increased external rotation with manual
testing. The remainder of his examination is
unremarkable.
RADIOGRAPHIC EVALUATION
Plain radiographs including flexion weight-
bearing and lateral views of the left knee reveal
no evidence of joint space narrowing. The bone
tunnels from prior ACL reconstruction are
appropriately positioned, and a fixation
screw is noted on the tibial side (Figure
C24.1A,B). Magnetic resonance imaging
(MRI) examination reveals almost complete
absence of the medial meniscus, with no sub-
chondral edema and intact articular cartilage
(Figure C24.1C).
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Case 24
81
FIGURE
C24.1.
Sizing X-rays obtained to plan fey
meniscal allograft reconstruction. Weight-bearii^
anteroposterior (A) and lateral (B) radiographs of
the left knee demonstrate preservation of the joint
space as well as prior anterior cruciate ligament
(ACL) fixation in good position. (C) MRI reveals
almost complete absence of the medial meniscus.
SURGICAL INTERVENTION
The patient was indicated for simultaneously
performed left knee medial meniscus allograft
transplantation and revision ACL reconstruc-
tion w^ith bone-patellar tendon-bone allograft.
The principal indications for this simultaneous
procedure included ipsilateral post-meniscec-
tomy pain and recurrent ACL insufficiency. The
primary indications for allograft meniscus trans-
plantation included pain and instability, with
consideration given to the role of the posterior
horn of the medial meniscus as a secondary sta-
bilizer to anterior translation. At the time of
surgery, the ACL was lax to probing and beUeved
to be attenuated (Figure C24.2A). Inspection of
the medial joint space revealed near absence of
the entire medial meniscus with relatively intact

articular cartilage (Figure C24.2B).
The medial meniscus allograft was prepared
using a double-bone plug technique. A 10-mm-
wide bone-patellar tendon-bone allograft
was fashioned with two
10
mm by
25
mm bone
blocks (Figure C24.2C). The posterior horn
tunnel for the medial meniscus was drilled
first, followed by the tibial and femoral tunnels,
respectively, for the ACL. The medial meniscus
was introduced and secured with vertical
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Case 24
FIGURE C24.2. (A) Lax and attenuated ACL appre-
ciated at arthroscopy. (B) Arthroscopy of the medial
compartment reveals nearly complete absence of
the medial meniscus with intact articular cartilage.
(C) Medial meniscus allograft and ACL allograft
terminally prepared before implantation. (D) ACL
allograft in position. (E) Medial meniscal allograft
secured in position.
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